Stand-alone surgery centers found lacking when it comes to infection control

By gerencherk

Freestanding surgery centers that get you in and out within 24 hours are an increasingly popular option over traditional hospitals for generally healthy people who have elective surgery, endoscopy or pain injections. But a new, first-of-its-kind study suggests lapses in widely accepted infection-control practices are common at ambulatory-surgery centers, though the study didn’t examine whether the lapses led to actual infections.

More than two-thirds of 68 freestanding surgery centers had at least one lapse in infection-control practices, and nearly 18% had lapses in three of the five categories measured, according to a study published in the June 9 issue of the Journal of the American Medical Association.

Infections that patients pick up while in health-care settings have been a growing concern in recent years. They’re a flash point in the debate over how to improve the quality of care in the U.S. as costs spiral out of control and medical spending consumes a growing portion of the gross domestic product.

Until recently, the main focus has been on hospitals. Every year, Americans suffer from about 2 million hospital-acquired infections, which lead to nearly 100,00 annual deaths, according to estimates from the Centers for Disease Control and Prevention (CDC). But as health care continues to become more outpatient-oriented, scrutiny of ambulatory settings is increasing. An outbreak of hepatitis C that was believed to be related to unsafe injection practices at a Las Vegas outpatient center a few years ago also raised the stakes.

Interpreting the study

In the JAMA study, surveyors armed with an audit tool assessed 68 surgery centers in three states. These centers weren’t targeted because of any known or suspected bad practices, and they knew they were being observed, said Dr. Melissa Schaefer, lead author of the report and medical officer in the division of health-care quality promotion at the CDC in Atlanta.

“These findings are kind of a reminder or wake-up [call] to all the facilities to proactively take a look at current practices and policies and make sure they’re based on national guidelines and that staff understand and are following them,” Schaefer said. But she cautioned that the study results shouldn’t deter patients from getting needed health care.

Among the volunteer participants were 32 ambulatory-surgery centers in Maryland, 16 in North Carolina and 20 in Oklahoma. Researchers were looking for compliance with five specific infection-control practices including hand washing, injection safety and medication handling, equipment reprocessing, environmental cleaning and handling of blood glucose-monitoring equipment.

“When these lapses were identified, the facilities were required to fix the problem,” Schaefer said, noting that many of the remedies involved “simple, quick fixes.”

The Centers for Medicare and Medicaid Services is inspecting a third of the more than 5,000 Medicare-certified ambulatory surgery centers nationwide, and the infection-control tool used in the study is available online to any health-care provider who wants it, she said.

The study shows that infection-control issues in outpatient surgery centers aren’t that different than in hospitals, said Lisa McGiffert, director of Consumers Union’s Safe Patient Project, based in Austin, Texas.

“The cleaning and disinfecting of equipment is a really important piece of this in these kind of facilities as well as in hospitals and does pose a real danger,” she said.

Ironically, many healthy patients are attracted to ambulatory surgery centers because of the ability to leave the facility sooner, which theoretically may reduce the risk of infection, McGiffert said. “A lot of people would rather not be in a hospital, where you might have to be there for several days and then you’re exposed to possibly getting some kind of bacteria in your body.”

Dr. David Shapiro, chair of the Ambulatory Surgery Center Association, a trade group, said the industry takes the study findings seriously and has started collecting data on itself voluntarily that consumers can use to compare different surgery centers in their area. Patients can see the latest ASC quality collaboration report online, and health-care providers can download a hand hygiene toolkit. He said the association’s outcomes monitoring project has found that 80% of 650 ASCs surveyed reported fewer than 1.5 post-surgical wound infections for every 1,000 patients.

ASCs wouldn’t have been able to grow as much as they have in the last 30 years if patients were increasingly dissatisfied with their health results, he said.

“There’s been a lot of activity since this study was conducted….to enhance the efforts of ASCs to address some of the findings,” Shapiro said.

“It’s our hope that in the future — and some of the new health-care reforms indicate that’s where government is going also — that patients will be able to see the good outcomes we’ve had in our [surgery centers] and compare them to other settings they’re thinking of having health care in as well as comparing costs and out-of-pocket expenses.”

What patients can do

McGiffert of Consumers Union suggests patients ask questions of the surgery center staff to get a dialogue going before having the procedure.

“I would definitely ask an outpatient center what’s your [infection] rate, tell me what you do to prevent infections in your facility in general and what are you going to do to prevent infections for me?” she said. “Those are really open-ended questions they should be able to answer.”

For example, the staff should give you an antibiotic within 60 minutes of surgery, she said.

In general, patient education at the time of discharge is often lacking in health-care settings and needs to be improved, McGiffert said. Be sure you’re clear on how to care for yourself at home and when to report a potential problem. Post-visit marketing surveys often don’t ask about these details and can distract patients from some of their most urgent follow-up priorities.

On a personal note, two years ago I asked an ambulatory surgery center to tell me its infection rate prior to having minimally-invasive surgery. They provided me with no hard numbers — only vague assurances that their rates were reasonably low and similar to that of their hospital competitors. It’s unclear if they had the information to begin with.

Happily, or luckily, the operation was a success and I found the nurses particularly professional. They called the next day to assess how I was recovering and even dropped off a prescription after a minor mix-up, both of which are more than I assume a hospital would have done. Still, I have no way of knowing whether an irritating, low-grade infection that developed at the top of my incision and lasted several months was related to the surgery center’s infection-control practices, my doctor’s oversight or the way I took care of my wound at home. That’s one of the mysteries that studies may never be able to untangle, but turning patients loose with more information about post-operative self-care could only help.

In my case, another complication was which doctor to see when the skin problem developed. The surgeon recommended seeing a dermatologist, but when I did he refused to even look at the wound. A specialist turf issue arose that left me with no one taking full responsibility for the problem. Fortunately, the infection resolved on its own but lesson learned. Should I need another procedure in the future, regardless of where I have it done I will ask ahead of time who is in charge of overseeing my post-operative wound care should an infection drag on. Hopefully that will help.

About Health Matters

Health Matters is a blog-style round-up of news and analysis concerning consumer health and the business of health care. The lead writer is MarketWatch reporter Kristen Gerencher, who also writes the Vital Signs column. Andrea Coombes and Jonathan Burton contribute editing. Gerencher won a 2006 explanatory journalism award from the Society of Professional Journalists-Northern California for a series she did on health savings accounts.